Absconding refers to the departure of patients from hospital wards without permission. The definition of absconding can vary depending on the length of time required for an absence to be considered absconding, and on the method of departure (e.g. leaving a locked ward, leaving the hospital grounds, or failing to return from day leave). Absconding status is influenced by the patient’s admission, whether it be voluntary, involuntary, or legally detained. There are significant implications of absconding for patients, carers and family members.

What is the evidence for absconding?

Moderate to low quality evidence suggests inpatients who abscond are often young men in the first three weeks following admission. Absconding may occur in up to 34% of admissions, and up to 80% of absconders return within 24 hours. A large proportion of absconders indicate intent to leave, and most commonly abscond directly from the ward. There is insufficient evidence regarding interventions for preventing absconding.

August 2020

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Differences are observed in the age at onset of psychotic symptoms, which may be influenced by genetic or environmental risk factors, or sex. Understanding the factors that impact on age at the onset of symptoms could lead to better understanding of the risk factors for the disorder and earlier and improved intervention strategies.

What is the evidence for age at onset of schizophrenia?

Moderate to high quality evidence suggests the median age at onset of schizophrenia is around 25 years old. The incidence (i.e., new cases) of schizophrenia is higher in males up until around 40 years of age, then higher in females after around 50 years of age. Substance use, in particular cannabis, is associated with an earlier age at onset of psychosis, with no effect of tobacco use. There was also a small effect of an earlier age at onset in people with a family history of psychosis.

Moderate quality evidence finds small associations between an earlier age at onset and more hospitalisations, more negative, but not positive symptoms, more relapses, poorer overall functioning, and poorer overall clinical outcomes (in males only).

March 2022

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Childhood-onset schizophrenia has an onset prior to the age of 13 years, and early-onset schizophrenia has an onset between the ages of 13 and 17 years.

What is the evidence on childhood and early-onset schizophrenia?

Moderate quality evidence suggests poorer long-term functioning in children and adolescents with early-onset schizophrenia compared to other psychiatric disorders.

August 2020

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A link between creativity and psychiatric disorders has long been postulated. This hypothetical connection has been the subject of many theoretical approaches, although theory and research results in this field are scattered and disparate.

What is the evidence for creativity in people with schizophrenia?

Moderate to low quality evidence finds a small association of lower creativity scores in people with schizophrenia compared to controls without a mental illness.

August 2020

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Criminal offending covers a wide range of behaviours from destructive acts, stealing, sexual assaults, to physical assaults causing injury or death. The majority of people with schizophrenia will never commit a crime, however the few who do may help perpetuate a negative public stereotype that schizophrenia is associated with violent behaviour. It is difficult to determine whether any criminal acts committed by people with schizophrenia are a consequence of the illness or are traits of the particular individual. This is confounded by the fact that people with schizophrenia may be at high risk of exposure to the social factors that contribute to criminal offending, such as social disadvantage and substance abuse.

What is the evidence for criminal offending, aggression and violence?

Any criminal offending

Moderate quality evidence found a small increased rate of offending in people with psychosis compared to general population rates. Moderate to low quality evidence suggests arrest rates in people with schizophrenia or bipolar disorder are around 40%, which is similar to arrest rates in people with other mental disorders. There was a small increased risk of repeat offending in people with schizophrenia compared to people with depression, or compared to the general population. There were no differences in repeat offending rates when comparing people with schizophrenia to people with substance use disorders, mental retardation, or learning disabilities.

Aggression

Moderate quality evidence suggests aggression rates in people with schizophrenia are around 33%, with verbal aggression being more common than physical aggression, or aggression towards property or self. Moderate to low quality evidence suggests the prevalence of any aggression in people during a first episode of psychosis is around 31%, and the prevalence of serious aggression is around 16%.There was a small, decreased risk of aggression in people with better cognitive functioning.

Moderate quality evidence suggests a large increased risk of inpatient aggression with a history of previous inpatient admissions, a small to medium-sized increased risk of inpatient aggression with a history of illicit substance abuse or involuntary admissions, and a small increased risk of inpatient aggression in males, people with schizophrenia, inpatients with a history of self-destructive behavior, and inpatients who are not married. Moderate to low quality evidence suggests a small increased risk of inpatient aggression in those with a history of violence, and in younger patients.

Violence

Moderate quality evidence suggests a small increased risk of violence in people with schizophrenia compared to the general population. The risk was lower in people with schizophrenia than in people with personality disorders. The factors associated with a large increased risk of violence were; previous violent victimisation, high verbal aggression, polysubstance use, non-adherence to psychological therapies, and previous hospital admissions. The factors associated with a medium-sized increased risk of violence were; homelessness, childhood maltreatment, aggression, hostility, any substance misuse, poor impulse control, psychopathy, antisocial personality disorder, a history of conviction, imprisonment, assault or involuntary hospital admission, and a lack of insight. The factors associated with a small increased risk of violence were; parental criminal involvement, parental alcohol misuse, previous suicide attempts, higher symptom scores, excitement and angry affect scores, non-white ethnicity, low socio-economic status, non-adherence to antipsychotic medication, and a history of self-destructive behaviour. For people with first-episode psychosis, involuntary treatment, hostility, having a forensic history, manic symptoms, illegal drug use, being male, being younger, and having a longer duration of untreated psychosis were associated with a medium-sized increase risk of violence.

Moderate to high quality evidence suggests a large increased risk of homicide in people with first-episode psychosis prior to treatment compared to after treatment. Prior to treatment, the rate of homicide in first-episode patients is around 0.16%, and after treatment it is around 0.01%. The proportion of stranger homicide by people with psychotic disorders is significantly lower than the proportion of other homicides.

August 2020

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Criminal victimisation refers to a person being the victim of a violent crime (rape or sexual assault, robbery, aggravated or simple assault) or a property crime (burglary and theft). People with a severe mental illness may be at higher risk of criminal victimisation. This may be a result of possible cognitive impairment (e.g. poor reality testing, judgment, social skills, planning, and problem solving), and sometimes compromised social situations (e.g. poverty, unemployment, homelessness, and social isolation).

What is the evidence for criminal victimisation?

Moderate quality evidence found increased rates of criminal victimisation in people with schizophrenia compared to general population rates. Between 43% and 83% of women with schizophrenia reported domestic violence by a partner.

In people with any psychotic disorder, rates of victimisation were around 20%. Criminal activity showed a medium to large association with increased victimisation. Small associations were found with having delusions, hallucinations, or mania symptoms. Being unemployed, homeless, or using drugs or alcohol also increased the risk of victimisation.

August 2020

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Cultural differences may influence the course and outcome of illness for people with schizophrenia. These may be the result of differences in understanding of mental illness, and different attitudes and treatment approaches towards these disorders. Some cultures may provide more accessible pathways to care than others, including ready access to treatment and family and social support that can assist the individual to better deal with symptoms and any associated distress. Negative cultural attitudes towards mental illness may exacerbate stigma and social isolation, and some cultures may focus more on “abnormal” behaviour than other cultures, potentially perpetuating it.

What is the evidence for cultural differences?

Overall, moderate quality evidence suggests rates of mortality, remission, relapse, social disability, marital status, and employment vary across studies conducted in different countries, both in the developing and the developed world.

There was a small increased risk of compulsory psychiatric admissions in migrant groups compared to native populations. Compared to white ethnic groups, there was a small increased risk of compulsory psychiatric admissions in Black Caribbean, Black African, South Asian, East Asian, and other minority groups. Black people in the UK were less likely to be hospitalised on first presentation to services, or to be referred to specialist services, but were more likely to have had involvement with the police during admission to hospital. The most common explanations for these findings include having psychotic symptoms, perceived risk of violence, police contact, absence of or mistrust of general practitioners, and ethnic disadvantages.

Moderate to low quality evidence indicates there may be fewer compulsory admissions for Asians in Canada with first-episode psychosis than for Whites, Blacks, or those of other ethnic backgrounds.

August 2020

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What is the evidence regarding diet ?
Moderate to low quality evidence finds poor dietary patterns in people with schizophrenia, including decreased fibre and fruit intake, and increased energy, sodium and saturated fat intake compared to people without a mental disorder. People with schizophrenia may have high LDL and low HDL blood levels, and increased fasting glucose.

Moderate to high quality evidence shows lower vitamin D levels compared to people without a mental disorder (large effect), and compared to people with other psychoses (small effect), with similar vitamin D levels compared to people with major depression.

Moderate quality evidence finds decreased folate levels, particularly in Caucasian and Asian people with schizophrenia, and in people with schizophrenia aged under 50 years. High quality evidence finds no differences in vitamin B12 levels in people with schizophrenia.

Moderate quality evidence shows people with first-episode psychosis also have a large effect of lower vitamin D levels, and a medium-sized effect of lower folate levels than people without a mental disorder. Moderate to low quality evidence also finds lower levels of vitamin C in people with first-episode psychosis, with no differences in B12, vitamin A, vitamin E, or any dietary mineral.

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Drug and alcohol misuse, abuse or dependence are concerns for people with schizophrenia due to the association with poor clinical and social outcomes, including high rates of suicide, HIV, homelessness, aggression and incarceration. Moreover, substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse. This topic covers outcomes for people with schizophrenia and comorbid substance use (termed ‘dual diagnosis’). Please also see the topic on rates of comorbid substance use, as well as substance use as a risk factor for schizophrenia.

What is the evidence on outcomes for people with schizophrenia and comorbid drug and alcohol use?

High quality evidence shows a small increase in positive symptoms, but a medium-sized reduction in negative symptoms in people with schizophrenia and any current substance use disorder compared to people with schizophrenia without a current substance use disorder. Moderate to high quality evidence finds patients with any current substance use are also more likely to have depressive symptoms.

Moderate to low quality evidence finds an increased risk of treatment non-adherence, relapse and re-hospitalisation in people with first-episode psychosis and cocaine, opiates, or ecstasy use. Patients with a mixed psychoactive substance use disorder or a cocaine use disorder also show increased extrapyramidal (movement) symptoms, particularly akathisia and tardive dyskinesia compared to patients without a substance use disorder.

For cannabis use, high quality evidence found a small to medium-sized decrease in negative symptoms in people with schizophrenia who recently abstained from cannabis use compared to people with schizophrenia with no cannabis use. There was a small increase in positive symptoms and hospital stay duration in people who continued cannabis use after the first onset of psychosis compared to non-users of cannabis. There were also higher rates of relapse in people who continued cannabis use compared to people who discontinued cannabis use after the first onset of psychosis. Cannabis use was also associated with and earlier age of onset of the disorder, more suspiciousness and unusual thought content in people at risk of psychosis.

For cognition, high quality evidence shows a small effect of lower current IQ, and a medium-sized effect of lower premorbid IQ in people with psychosis and current cannabis use compared to people with psychosis without current cannabis use. Moderate quality evidence also finds poorer verbal working memory in those currently using cannabis. For people with schizophrenia specifically, moderate to high quality evidence finds a medium-sized effect of better global cognition, processing speed, planning, and visual and working memory in those with any history of cannabis use, but not in those with current cannabis use. Similarly, high quality evidence shows a small to medium-sized increase in global cognition, processing speed, planning, visual and working memory, attention, and psychomotor skills in people with psychosis and a polysubstance or cannabis use disorder compared to people with psychosis with no substance use disorder. For people with psychosis and an alcohol use disorder, moderate quality evidence finds more impaired working memory compared to people with psychosis and no substance use disorder.

March 2022

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DUP is generally determined as the time from the onset of psychotic symptoms to the initiation of treatment or first clinical presentation, when a diagnosis of first-episode psychosis may be given. Longer DUP has been associated with poorer prognosis (see the DUP and outcomes topic). As such, understanding the effects of DUP is particularly important because it is potentially modifiable.

What is the evidence for DUP?

Moderate to high quality evidence indicates the presence of an obligatory dangerousness criterion for compulsory treatment of mental illness is associated with longer DUP.  Moderate quality evidence finds people with schizophrenia or non-affective psychosis have a longer DUP (~28 weeks) than people with affective psychosis, regardless of age or sex. Longer DUP was also found in low-middle income countries than in high income countries, and Black Caribbean people have longer DUP than White people, while Black African people have shorter DUP than White people. Moderate to low quality evidence shows emergency services and inpatient units are associated with a shorter DUP than community services pathways to care.

Long-term, widespread educational campaigns covering multiple domains such as advertising, distribution of brochures, visits to GPs and schools, training seminars, and follow-up contact may reduce the length of DUP. A one-dimensional campaign approach, such as solely educating GPs, may not be as effective.

August 2020

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